Will Medicare Cover My Breast Reduction?

Is Breast Reduction Surgery Covered By Medicare?

You may be familiar with Medicare, the government-funded health care system that provides citizens and most permanent residents access to a wide range of health services at little or no cost. However, you may be wondering about the extent of the coverage it provides, particularly for procedures such as breast reduction surgery. While Medicare is comprehensive, it doesn’t cover everything. There are some services and procedures that it doesn’t fully cover, and for these, you may need additional financial support

Melbourne Specialist Plastic Surgeon Dr Carmen Munteanu is renowned for her experience in performing breast reduction procedures. With a comprehensive understanding of the human anatomy, a keen aesthetic eye, and a patient-centred approach, Dr Munteanu provides individualised care for each of her patients, ensuring that their needs and concerns are addressed thoroughly. She is experienced in performing complex surgeries and is meticulous in her work, aiming to provide optimal results by tailoring each procedure to the patient’s unique needs and health condition.

Take our Plastic Surgery Quiz to find out if you’d be a good candidate and if you are ready for cosmetic surgery.

What Is Medicare Coverage?

When it comes to understanding the coverage offered by Medicare, it’s essential to note that it primarily focuses on medically necessary treatments. This includes general practitioner visits, specialist consultations, tests and scans like x-rays, and most surgical procedures performed by doctors.

However, there are certain treatments and procedures that do not fall under the umbrella of Medicare coverage. These usually include cosmetic surgeries, which are procedures performed to enhance appearance rather than address a medical issue. So, where does this leave breast reduction surgery and its coverage by Medicare?

Breast reduction surgery, also known as reduction mammoplasty, can be a medically necessary procedure for some individuals. For others, it may be considered a cosmetic procedure. This distinction is crucial when it comes to understanding Medicare coverage for breast reduction surgery.

Is Breast Reduction Surgery Covered Under Medicare?

Breast reduction surgery is a procedure that removes excess breast fat, glandular tissue, and skin to achieve a breast size in proportion with your body. The surgery might be an option if you have large breasts that cause physical discomfort, including back pain, neck pain, or skin irritation.

This surgery is not only performed for cosmetic reasons. For many individuals, having excessively large breasts can lead to various health problems, from neck and back pain to skeletal deformities and breathing problems. Despite the potential health benefits, you might be asking the question: is breast reduction surgery covered under Medicare? To answer that, you need to understand the concept of Medicare Item Numbers for breast reduction.

If Dr Carmen determines that your breast reduction surgery is necessary for medical reasons, she will assign a Medicare Item Number to your procedure. This number signifies that the service is recognised by Medicare and that a benefit may be paid towards the cost of the procedure.

It’s essential to note that even if your surgery has a Medicare Item Number, this doesn’t mean that Medicare will cover the entire cost. There will still be out-of-pocket expenses, such as surgeon’s fees, anaesthetist’s fees, and hospital costs that you will need to pay.

Medicare Item Numbers for Breast Reduction

Medicare Item Numbers for breast reduction surgery are codes for specific health services. These codes are used to determine the amount of benefit you can receive from Medicare for your surgery.

Each Item Number corresponds to a specific surgical procedure and has a set benefit amount associated with it. For instance, the Medicare Item Numbers for breast reduction surgery for medical reasons are 45520 and 45523. If your surgery falls under this Item Number, Medicare will pay a benefit towards the cost of your procedure.

·       Medicare Item Number 45520  

Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast

·       Medicare Item Number 45523  

Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:

(a) for patients with macromastia and experiencing pain in the neck or shoulder region; and

(b) not with insertion of any prosthesis

Keep in mind that the benefit amount is less than the actual cost of the surgery. This means you may still have significant out-of-pocket expenses, even if your procedure is covered by Medicare.

Download Dr Carmen’s Guide to Breast Reduction Surgery – Reduction Mammaplasty

Can Super Pay for Plastic Surgery?

You may be wondering, if there are still out-of-pocket costs after Medicare coverage, can Super pay for plastic surgery? Super, or superannuation, is a way Australians can save for their retirement. In certain circumstances, you may be able to access your super early on compassionate grounds, which could include medical procedures.

Early release of super is strictly regulated and only granted in specific circumstances. If you are considering accessing your super to pay for breast reduction surgery, it’s essential to seek professional advice to understand the potential implications for your future retirement savings.

Private Health Insurance for Breast Reduction

In addition to Medicare and your Super, another potential source of funding for breast reduction surgery is private health insurance. Many private health insurance policies offer coverage for plastic and reconstructive surgery, including breast reduction surgery.

The level of coverage and the out-of-pocket costs will depend on your specific policy. It’s also important to note that most insurance companies have a waiting period before you can claim benefits for certain procedures. Therefore, it’s crucial to thoroughly understand your policy before proceeding with surgery.

Criteria and Considerations for Medicare and Health Insurance Coverage

When considering breast reduction surgery and looking into Medicare coverage or private health insurance, it’s important to understand the criteria and considerations involved. For Medicare, you’ll need to meet specific criteria to have your surgery classified as medically necessary and receive a Medicare Item Number.

For private health insurance, coverage will depend on the specifics of your policy. Some policies may cover breast reduction surgery if it’s deemed medically necessary, while others may only cover it if it’s due to a congenital abnormality or as part of reconstructive surgery following a mastectomy.

Steps to Get Your Breast Reduction Surgery Covered by Medicare

Navigating the process of getting your breast reduction surgery covered can be daunting. The first step is consulting with your plastic surgeon to determine whether your surgery can be classified as medically necessary.

Here are steps you can follow to get your surgery covered:

1. Understand Medicare’s Rules: Medicare will generally cover breast reduction surgery if it’s required for health reasons rather than purely cosmetic. This could include problems such as back, neck, or shoulder pain, skin irritation, or limitations in daily activities due to large breasts. It’s essential to understand these rules before moving forward
2. Consult with Your GP: Discuss your symptoms and concerns with your General Practitioner (GP). If you have health issues that could be linked to the size of your breasts, such as chronic pain, skin infections or other issues, your GP can provide documentation of these problems and potentially refer you to a specialist
3. See a Specialist: A referral from your GP can lead you to a specialist, usually a plastic surgeon, who can further assess your condition. They can provide a professional opinion on whether breast reduction surgery is medically necessary in your case
4. Document your Symptoms: Keep a log of your symptoms, when they occur, and how they impact your daily life. This evidence can be useful when making your case to Medicare and your health insurance provider
5. Undergo Required Tests: The specialist may request certain medical tests to determine the severity of your symptoms. This could include X-rays or MRIs of your back or neck to illustrate the physical strain caused by the weight of your breasts
6. Understand the Amount Covered: Medicare typically covers 75% of the Medicare Benefits Schedule (MBS) fee for in-hospital treatments. You should familiarise yourself with these details and understand any out-of-pocket costs you might have to bear
7. Understand Hospital and Surgeon Fees: You’ll need to discuss the costs with your plastic surgeon and the hospital to understand if there are any extra fees not covered by Medicare
8. Seek Private Health Insurance: If you have private health insurance, speak with your provider. They may cover additional costs not covered by Medicare, depending on your policy

Remember, every case is unique, and getting approval can take time and require effort. It is critical to maintain open communication with your healthcare providers throughout the process. Consult with professionals, collect as much evidence as possible, and ensure your documentation is thorough and accurate for the best chance of success.

FAQs about Medicare and Breast Reduction Surgery

What conditions must be met for Medicare to cover breast reduction surgery?

• Medicare will generally cover breast reduction surgery if it’s required for health reasons. This could include chronic pain, discomfort, skin irritations, or physical limitations due to large breasts. Your GP and a specialist plastic surgeon should document your symptoms, and medical tests may be needed to support the claim.

How much of the surgery cost does Medicare cover?

• If your claim is approved, Medicare typically covers 75% of the Medicare Benefits Schedule (MBS) fee for in-hospital treatments. You should familiarise yourself with these details and understand any out-of-pocket costs you might have to bear.

What’s the process to get Medicare coverage for my breast reduction surgery?

• The process involves discussing your symptoms with your GP, getting a referral to a specialist, undergoing any necessary medical tests, and documenting your symptoms and their impact on your life. Your specialist will then determine whether you meet the criteria for that item number.

If I have private health insurance, will it cover the costs not covered by Medicare?

• If you have private health insurance, you should discuss this with your insurance provider. They may cover additional costs not covered by Medicare, depending on your policy. Be sure to understand what your policy includes and excludes to avoid surprise expenses.

Will Medicare cover me if I want a breast reduction for cosmetic reasons?

• Generally, Medicare does not cover cosmetic procedures. If you’re seeking breast reduction for aesthetic purposes only, without medical necessity, it’s unlikely that Medicare will cover the costs.

Further Reading about Breast Surgery with Dr Carmen

• Read Dr Carmen’s Breast Reduction Surgery Page
• Read Dr Carmen’s Medicare for Plastic Surgery Page
• Read Dr Carmen’s Blog about Recovery after Breast Reduction Surgery
• See Dr Carmen’s Before and After Photos of Breast Reduction Patients
• Read Dr Carmen’s Blog about Breast Reduction FAQs – Dr Carmen’s Q & A about Breast Reduction
• Read Dr Carmen’s Blog about How Can I Reduce Swelling and Bruising After Breast Reduction Surgery
• Read Dr Carmen’s Blog about How to Reduce Scars after Breast Reduction

Medical References about Breast Reduction Surgery and Medicare

• What is a breast reduction and what are the benefits of this procedure?
• MBS Online – MBS Online
• Medicare – Services Australia
• Breast reduction surgery: Procedure, recovery, and risks
• What to expect after your breast reduction surgery | ASPS